1. The document discusses various deformities that can result from polio, including flexion-abduction deformities of the hip and paralysis of specific muscles like the gluteals. 2. Surgical procedures to correct deformities are described, such as the Ober-Yount procedure for hip flexion-abduction contractures and the Sharrard/Mustard procedures to transfer the iliopsoas muscle for gluteal paralysis. 3. Paralytic dislocation of the hip and treatment methods including reduction, muscle transfers, and osteotomies are also summarized.

1. SRI SIDDHARTHA MEDICAL
COLLEGE,TUMKUR
Subject seminar
Poliomyelitis part- 2
(Deformities and correction)
CHAIRPERSON: PROF. & HOD Dr. Kiran Kalaiah
MODERATOR: PROF. & HOD Dr. Kiran Kalaiah
SPEAKER: Dr. G. ARUN SIVA RAM

2. Deformities of lower limb

3. • During acute and convalescent stage , patient lies in frog leg
position due to spasm of hip flexors, hip abductor , TFL ,
hamstrings .
• Hip-flexion abduction , external rotation , knee- flexion, foot -
equinovarus
• Soft tissue contractions : Inter-muscular septa , facia over
muscles—> fibrosis of muscles—> contractures

4. Most common deformities of lower limb
• 1. Flexion-abduction deformity of hip
• 2. Pelvic tilt / obliquity : hip abduction contracture—> opposite
side of pelvis ride high—> hip adduction , subluxation
• 3. Exaggerated lumbar lordosis & anterior inclination of pelvis
secondary to hip flexion contracture -

5. • 4. Lumbar scoliosis convex towards affected side
• 5. External torsion of leg on femur
• 6. Genuvalgum & flexion of knee , Genu Recurvatum
• 7. Equinovarus of foot

6. Deformities of HIP
HIP Paralysis of muscle around hip can cause
1. Flexion & abduction contracture
2. Instability & limping due to paralysis of gluteus maximus and
medius
3. Paralytic hip dislocation

7. Flexion-Abduction contracture
• Abduction deformity- Mc deformity
• Occurs in conjunction with flexion & external rotation
• Sometimes - adduction with flexion & IR occurs
• If contracture is B/L & severe- locomotion only as quadruped

8. Fascia lata & iliotibial band
• Deep fascia of the thigh
• Encloses muscles of thigh
• Forms the outer limit of the fascial compartments of thigh, which
are internally separated by inter-muscular septa
• Thickened at its lateral side- iliotibial tract

9. Iliotibial band contracture
• 1.Flexion, abduction, and external rotation contracture of
the hip
• -Iliotibial band lies lateral and anterior to the hip joint,
contracture can cause flexion and abduction
• -Externally rotated for comfort only
• -If not corrected, external rotators contract & contribute to a
fixed deformity.

10. 2. Genu valgum and flexion contracture of the knee
3. Limb-length discrepancy
-related more to the loss of neurologic and muscle function
-contracted iliotibial band on one side may be associated with
considerable shortening of that extremity after years of growth

11. 4. External tibial torsion, with or without knee joint
subluxation:
- Tibia and fibula externally rotated on femur
-If severe, lateral tibial condyle subluxates on the lateral femoral
condyle and the head of the fibula lies in the popliteal space.
5. Secondary ankle and foot deformities
With external torsion of the tibia, the axes of the ankle and knee
joints are malaligne

12. • 6. Pelvic obliquity :
• patient is supine with the hip in abduction and flexion, the pelvis
remains at a right angle to the long axis of the spine When the
patient stands, affected extremity is brought into the weight-
bearing position—pelvis becomes oblique—lower on affected
side
• lateral thrust forces pelvis towards unaffected side
• Trunk muscles lengthen on affected side, contracted on
unaffected side

13. 7. Increased lumbar lordosis :
‣ To maintain upright erect posture, compensatory lumbar
lordosis develops

14. Measures to prevent flexion-abduction
deformity
During acute & convalescent stages
• hip in neutral rotation
• slight abduction , No flexion
• full range of passive motion in all joints several times in a day
• to prevent rotation, a bar similar to Denis-Browne splint is used

15. Surgical correction
• Minor contracture- simple fasciotomy around hip & knee
• For AB-ER - complete release of hip muscles (OBER- YOUNT)
•
• For severe deformities - complete release of all muscles from
iliac wing with transfer of crest of ilium (CAMPBELL
TECHNIQUE)

16. Ober-yount procedure

17. • Complete release of flexion abduction & external rotation
contracture
• Position : lateral
• Incision : transverse just medial & distal to ASIS, extending
laterally above GT
• Divide ilio-psoas tendon, excise 1cm

18. • Sartorius origin detached from ASIS
• Rectus femoris origin detached from AIIS
• TFL divided from anterior to posterior
• Gluteus medius, minimus & short external rotators detached
from insertion on trochanter

19. • Sciatic nerve retracted , hip capsule opened from anterior to
posterior
• Hip spica cast applied with hip in full extension, 10deg
abduction & internal rotation

21. Yount procedure
• Lateral longitudinal incision just proximal to femoral condyle
• Fascia lata exposed
• Ilio-tibial band & fascia lata divided anteriorly upto midline of
thigh, 2.5 cms proximal to patella, posteriorly upto biceps
tendon

22. • IT band & lat intermuscular septum of 5-8 cms long excised •
• Post-operative care: cast removed at 2 weeks , long leg brace
with pelvic band applied with hip in same position

23. Campbell technique

24. • For severe deformities
• Complete release of muscles from iliac wing & transfer of crest
of ilium
• incision : skin along anterior 1/2 or 2/3 of iliac crest upto ASIS,
extended distally for 5-10 cms on anterior surface of thigh

25. • superficial & deep fascia divided
• Origins of TFL, gluteus medius, minimus stripped
subperiosteally from wing of ilium to acetabulum
• Free proximal part of sartorius from TFL

26. • With an osteotome, asis with origin of sartorius resected
• Anterior border of ilium denuded down to AIIS
• Free attachments of abdominal muscles from iliac crest
• Iliacus stripped subperiosteally

27. • Detach straight head of rectus from AIIS & reflected head from
anterior margin of acetabulum
• As result hip hyperextension without lordosis should be
possible
• If not then divide capsule obliquely from proximal to distal +
tenotomy of Iliopsoas from LT

28. • Redundant part of denuded ilium is resected
• Abdominal muscles sutured to edge of gluteal muscles &TFL
• Superficial fascia on medial side of incision sutured to deep
fascia on lateral side to bring skin incision 2.5 cms posterior to
rim of ilium

29. • In a child, all steps are followed except iliacus is not stripped
• A wedge of crest of ilium removed distal to physis from anterior
to posterior with apex as far as skin incision, base anterior &
2.5cms in width

30. • Displace crest of ilium distally to contact main part of ilium , fix
with sutures
• Post-operative care: hip spica cast wit hip in hyperextension ,
10deg abduction for 3-4 weeks
• Cast removed & hip mobilised

31. Paralysis of gluteal muscles

32. • Weakness or paralysis of gluteus Maximus and medius
• Results in one of the most severe disabilities
• Paralysis causes unstable hip & unsightly, fatiguing limp

33. • If glut med alone is paralysed, during weight bearing-trunk
sways towards affected side, pelvis elevates on opposite side-
compensated trendelenburg gait
• If glut max alone is paralysed - body lurches backward
• trendelenburg test is used to test strength of gluteal muscles

35. ILIO-PSOAS TRANSFER
• Ilio-psoas is the most effective muscle
• Innervation is different, often preserved in polio
• Has good power • When transferred, acts in direct line to GT
• Although gluteal limp is reduced, normal balance is never
restored
• If glutei are partially paralysed, reinforcement markedly
improves stability and gait

36. • When gluteus medius is chiefly involved & abductor power is
the chief requirement- MUSTARD PROCEDURE is done
• If both glutei are involved i.e both abduction & extension are
weak- SHARRARD PROCEDURE is done

37. Sharrard procedure
Posterior transfer of the iliopsoas for paralysis of the gluteus
medius and maximus muscles
Open adductor tenotomy should always precede iliopsoas
transfer.
▪ Place the patient on the operating table slightly tilted toward the
nonoperative side. Through a transverse incision overlying the
adductor longus, adductor muscles exposed & divided
▪ lesser trochanter exposed and detached from femur, psoas
muscle cleared as far proximally as possible

38. • second incision is given just below and parallel to the iliac crest.
• crest with the muscles of the abdominal wall detached and
psoas muscle sheath opened Locate the insertion of the muscle
with a fingertip

39. • Through the first incision, LT grasped with a Kocher forceps and
pulled upwards, within the psoas sheath and into the upper
operative area
• Expose sartorius muscle and divide it in its proximal half
• Direct head of the rectus femoris muscle divided at its origin,
reflected head of the rectus femoris muscle dissected free from
the hip capsule, and elevated posteriorly.

40. • If the hip is dislocated, capsule is opened anteriorly and
laterally, parallel to the labrum, excise the ligamentum teres,
and remove any hypertrophic pulvinar.
• Hip joint reduced

41. • With awls & burs and from anteriorly to posteriorly, hole is
made through the greater trochanter big enough to receive the
tendon.
• While the hip is held in abduction, extension, and neutral
rotation, pass the end of the tendon through the buttock and
from posteriorly to anteriorly through the tunnel in the greater
trochanter

42. • Psoas and lesser trochanter are secured to the greater
trochanter with sutures or a screw
• Origin of the iliacus muscle is sutured to the ilium, inferior to the
crest.
• For severe coxa valga or anteversion that requires more than
20 to 30 degrees of abduction for stability, a varus derotation
osteotomy with internal fixation can be performed before
insertion and suturing of the iliopsoas tendon in the GT

43. • As an alternative, a “gutter,” or notch is cut into the posterior
lateral iliac crest rather than a window in the ilium.
• The muscle and its tendon can be redirected laterally through
the notch and inserted into the greater trochanter.
• This is technically simpler because the iliacus muscle is not
transferred to the outside of the pelvis.
POSTOPERATIVE CARE: The hip is immobilized for 6 weeks in
an abduction spica cast

45. MUSTARD PROCEDURE
• Indication: power of abduction be improved
• Smith-petersen incision
• Orgin od sartorius & rectus femoris removed
• Femoral vessels & nerve retracted medially

46. • Ilio-psoas divided at insertion
• Notch is cut in ilium between superior and inferior iliac spines
• Ilio-psoas is drawn through notch & attached to GT
• Hip maintained in abduction for several weeks

49. Paralytic dislocation of hip
• Paralyzed gluteal muscles with normal flexors and adductors of
the hip, the child may develop a paralytic dislocation of the hip
• Combination of imbalance in muscle power, habitually faulty
postures, and growth is important in producing deformity
• Dislocation also can develop because of fixed pelvic obliquity, in
which the hip is held in marked abduction, usually by a tight
iliotibial band or a structural scoliosis

50. • Weakness of the abductor musculature retards the growth of
the greater trochanteric apophysis.
• The proximal femoral capital epiphysis continues to grow away
from the greater trochanter and increases the valgus deformity
of the femoral neck;
• Femoral anteversion also may be increased
• Hip becomes mechanically unstable and gradually subluxates ‣
Uneven pressure in the acetabulum causes an increased
obliquity in the acetabular roof.

51. Treatment
• 1. Reduction of dislocation:
• Early: easily reduced by abduction
• Later: by traction & abduction
• Late: if contracture is severe—> adductor tenotomy with traction
If still irreducible—> skeletal traction continued till femoral head is opp
acetabulum, 30deg abduction & open reduction done

52. 2. Correction of muscle imbalance: To restore abduction &
extension by Iliopsoas transfer by MUSTARD / SHARRARD
procedure
3. Varus femoral osteotomy: To correct valgus deformity
4. Acetabuloplasty : To provide adequate roof & depth for
stability by salter, pemberton , chiari procedures
5.pelvic support osteotomy: rare

53. Hip arthrodesis:
• Rarely is indicated
• Last alternative for treatment of a flail hip that requires
stabilisation or
• of an arthritic hip in a young adult that cannot be corrected with
total hip arthroplasty
• Girdlestone procedure is the final option for failed correction of
the dislocation

54. FLAIL HIP
• Seen in extensive involvement of lower extremity with complete
lack of muscle power
• Requires multiple orthotic devices & support from upper limbs
• Gait is lurching & unstable , poor endurance, lacks support from
contralateral limb
• Ambulation is impossible with weakness of upper limbs

55. Treatment of flail hip
Arthrodesis of hip improves gait, stability, endurance and
eliminates need for external support
Principles:
• Hip fusion alone or combined with ankle fusion in slight
equinus—> good stability

56. • For hip fusion
a) good abdominal muscle power/ a strong opp glut med.
providing hip elevating power
b) knee ligaments should be sound
c) absence of flexion contracture of knee
Fusion involves combined intra & extra articular fusion
supplemented by internal fixation

57. Best position is
1. Neutral rotation
2. No adduction
3. No abduction
4. 30* flexion
5. In females & with shorter extremities 15*abduction

58. Deformities around foot and ankle

60. PARALYSIS OF SPECIFIC MUSCLES
• Tibialis anterior: Origin: upper ½ or 2/3 of lateral surface of
shaft of tibia and adjacent interosseus membrane.
• Insertion: medial cuneiform & base of 1st metatarsal.
• Action: Dorsiflexion & inversion
• Nerve supply: Deep peroneal nerve (L5).
• Arterial supply: Anterior tibial artery.
• Antagonists: Tibialis Posterior, Gastrocnemius-Soleus,
Peroneus longus

61. • Paralysis causes — loss of dorsiflexion , inversion ,Equinus,
Cavus, Planovalgus
• Extensors of toe become overactive resulting in hyperextension
of proximal phalanges, depression of MT heads
• Cavovarus results from unopposed activity of PL & posterior
tibial muscle

63. • Correction of Equinus contracture- passive stretching & serial
casting
• Sx: Posterior ankle capsulotomy + Achilles tendon lengthening
+ Anterior transfer of PL tendon to base of 2nd MT ( OR) EDL
can be recessed to dorsum of midfoot.
•

64. • Correction of claw toe deformity— Transfer of long toe
extensors to necks of metatarsals.
• Correction of cavovarus deformity— PL transferred to base of
2nd MT + EHL transferred to neck of 1st MT

65. Anterior & posterior tibial muscles
• -results in equinovalgus valgus = eversion + abduction -
shortening of Achilles tendon & peroneal muscles—>fixed
deformity.
• deformity is similar to congenital vertical talus on standing
lateral radiograph.
• serial casting before surgery to stretch Achilles tendon & to
avoid weakening of gastro-soleus

66. Anterior & posterior tibial muscles
• - if both tibialis muscles are paralysed and peroneal muscles
are normal,
• 1)PL transferred to base of 2nd metatarsal (to replace anterior
tibialis)
• 2)One of the long toe flexors replaces posterior tibialis -
Peroneus brevis is sutured to distal stump of PL tendon

67. Tibialis Posterior
• Origin: posterior surface of interosseous membrane & adjacent
region of tibia & fibula.
• Insertion: Tuberosity of navicular,medial cuneiform. Action:
Inversion and plantar flexion
• Nerve supply: Tibial nerve (L4,L5).
• Arterial supply: Posterior tibial artery.
• Antagonists: peroneus longus and brevis

69. • Tibialis Posterior Isolated paralysis is rare—> Hind foot & fore
foot eversion
• Surgery: FDL tendon is transferred and attached to navicular
For 3-6 yrs old — conjoined EDL & peronius tertius tendons
through transverse tunnel in talar neck & tendon sutured back
onto itself.

70. • For severe valgus
• 1) PL transferred to medial side of talar neck
• 2)PB transferred to lateral side of talar neck

71. Anterior Tibial, Toe Extensors & Peroneal
muscles
• Severe equinovarus develops when posterior tibial &
Gastrocnemius- Soleus are unopposed.
• Posterior tibialis muscle increases forefoot Equinus & Cavus
deformity

72. Management:
• 1) Stretching by serial casting
• 2) Lengthening of Achilles tendon
• 3) Radical soft tissue release of forefoot cavus deformity
• 4) Anterior transfer of Posterior tibialis to base of 3rd
• MT/middle cuneiform & anterior transfer of long toe flexors.

73. Peroneus longus:
• Origin: Upper lateral surface of fibula, head of fibula, lateral
tibial condyle.
• Insertion: Under surface of lateral sides of distal end of medial
cuneiform & base of 1st MT
• Action: Eversion & plantar flexion Nerve supply: Superficial
peroneal nerve (L5,S1)

74. Peroneus brevis:
• Origin: lower 2/3rd of the lateral surface of the shaft of fibula.
•
• Insertion: lateral tubercle at the base of 5th metatarsal
• Action: Eversion of foot
• Nerve supply: Superficial Peroneal Nerve (L5,S1)

75. Peroneal muscles
• Isolated paralysis of peroneal muscles is rare, if present hind
foot varus deformity due to unopposed activity of tibialis
posterior.
• Calcaneus becomes inverted, fore foot adducted, varus is
increased during gait by action of invertors.
• Unopposed tibialis anterior —>dorsal bunion.

76. Management:
• 1) Anterior tibialis transferred to base of 2nd MT
• 2) Isolated transfer —>overactivity of EHL —> hyperextension
of hallux —> painful callus under 1st metatarsal head.
• 3) In chidren <5yrs, lengthening of EHL tendon.
• 4) >5yrs – transfer of EHL to neck of 1st metatarsa

77. Peroneal and Long toe extensors
• Causes less severe equinovarus deformity
• Surgery: -Transfer of anterior tibial tendon to base of 3rd
metatarsal/middle cuneiform.

78. Gastrocnemius-Soleus
• Strong muscle group, lifts entire body weight
• Paralysis with unopposed dorsiflexors results in calcaneal
deformity

79. • Adequate tension in Achilles tendon is required for normal
function of long toe flexors & extensors & intrinsic muscles
• Weak Gastrocnemius-Soleus—posterior tibial, peroneal
muscles & long toe flexors can’t plantar flex hindfoot but can
depress metatarsal heads—> Equinus

80. Gastrocnemius-Soleus
• Shortening of intrinsics and plantar fascia —>forefoot cavus
• Long axis of tibia and calcaneus coincide
• Surgical correction is indicated to prevent development of
calcaneal deformity and to restore hind foot plantar flexion.

81. • Surgery: Tendon transfer posteriorly to supplement/ substitute
gastro-soleus.
• if power is fair- posterior transfer of 2 or 3 muscles is sufficient
• if completely paralysed- all available muscles transferred.

82. FLAIL FOOT
• When all muscles distal to knee are paralysed – equinus
deformity results due to passive plantar flexion.
• Residual intrinsic muscle activity- forefoot equinus /cavo
equinus deformity.
• Surgery: Radical plantar release + Plantar neurectomy Midfoot
wedge resection for forefoot equinus

83. DORSAL BUNION
• Shaft of first meta tarsal is dorsiflexed, great toe is plantar
flexed.
• Results from muscle imbalance.
• Deformity becomes more on weight bearing.
• MTP joint is flexed, first MT head is displaced upwards, first
cuneiform tilted upwards.

84. • Exostosis forms on dorsum of metatarsal head.
• Flexion of great toe –>subluxation of MTP joints –> plantar part
of joint capsule and FHB gets contracted.

85. • Two types of muscle imbalance cause bunion.
Most common-
• Dorsiflexion of first MT (1*)
• Plantar flexion of great toe(2*)
• 2) Plantar flexion of great toe(1*)
• Dorsiflexion of first MT (2*)
• Most common muscle imbalance is between anterior tibial and
peroneus longus.

86. • Anterior tibial raises first cuneiform and base of first metatarsal,
PL has opposite action
• If PL is weak/ parlysed/ transferred – first MT dorsi flexed by
anterior tibialis.
• Great toe becomes actively plantar flexed.
• Dorsal bunions result after ill advised tendon transfer.

87. • If anterior tibial is paralysed, then PL tendon/ PL+ PB should be
transferred to third cuneiform rather than to insertion of anterior
tibial or PB transferred to insertion of anterior tibial.
• If PL tendon is transferred, proximal end of distal segment
should be fixed to the bone.
• If triceps surae is weak/ paralysed- PL transferred to
calcaneum, anterior tibial to midline of foot

88. BONY PROCEDURES (OSTEOTOMY
AND ARTHRODESIS)
• The no of joints that are controlled by paralysed muscles should
be reduced by arthrodesis.
• Stabilizing procedures for ankle and foot are of 5 types
1. Calcaneal osteotomy
2. Extra articular subtalar arthrodesis
3. Ankle arthrodesis
4. Triple arthrodesis
5. Bone blocks to limit motion at ankle joint

89. CALCANEAL OSTEOTOMY
• For correction of hindfoot varus/ valgus in growing children.
• For cavo varus, it can be combined with release of intrisic
muscles and plantar fascia.
• For calcaneovarus, it is combined with posterior displacement
calcaneal osteotomy.
• Fixed valgus deformity requires medial displacement osteotomy

90. DILLWYN EVANS OSTEOTOMY
• For talipes calcaneovalgus as an alternative to triple
arthrodesis in children between 8-12 yrs.
• Reverse of the original technique used in clubfoot
• Lengthens calcaneus by transverse osteotomy and insertion of
bone graft to open a wedge and lengthen lateral border of foot

92. SUBTALAR ARTHRODESIS
• For correction of equino valgus deformity.
• Deformity d/t paralysis of anterior and posterior tibial —
>unapposed action of peroneals (valgus) and gastro soleus
(equinus).
• Calcaneus is everted, displaced laterally and posteriorly.
• Two techniques for sub talar arthrodesis.
1) Grice and Green
2) Dennyson and Fulford

93. GRICE AND GREEN ARTHRODESIS:
• Extra articular subtalar fusion.
• To restore height of medial longitudinal arch in children between
3-8 yrs.
• Done when valgus deformity is localized to subtalar joint and
calcaneus can be manipulated into normal position.

94. • Contraindicated when forefoot is not mobile enough to be made
plantigrade.
• Complictions: varus deformity and increased ankle joint valgus
due to over correction

95. Grice & Green Arthrodesis
• Curvilinear incision on lateral aspect of foot over subtalar joint
• Soft tissue dissection
• Subtalar joint reached
• Foot is inverted to position calcaneus beneath talus
• Graft beds prepared by removing thin layer of cortical bone
from inferior surface of talus & superior surface of calcaneus

96. • Bone graft harvested & shaped
• Grafts placed in sinus tarsi, with foot in over corrected position
• Long leg cast applied with knee flexion, ankle in maximum
dorsiflexion, foot in corrected position

97. Grice & Green Arthrodesis

98. DENNYSON AND FULFORD
ARTHRODESIS:
• Screw is inserted across subtalar joint for internal fixation and
an iliac graft is placed in sinus tarsi

99. Dennyson & Fullford Arthrodesis
• Oblique incision over sinus tarsi, sinus tarsi exposed
• With calcaneum in corrected position, bone awl is passed
through neck of talus across sinus tarsi, upper surface of
calcaneus, inferolateral surface of calcaneus

100. • Mini fragment cancellous screw is passed across subtalar joint
from neck of talus into calcaneus
• Sinus tarsi filled with iliac crest bone graft

102. Triple Arthrodesis
• Most effective stabilising procedure in foot
• Fusion of
1) Sub-talar joint
2) Calcaneo-Cuboid joint
3) Talo- Navicular joint
• Allows only movement at ankle
• Indicated when most of the weakness & deformity are at sub-
talar & mid tarsal joints

103. steps
1. Oblique incision over sinus tarsi
2. Soft tissue dissection
3. Capsules of all 3 joints incised circumferentially
4. Appropriate bone wedges removed
5. Bone graft placed around talonavicular joint & in sinus tarsi
6. Correction maintained with steinmann pins or k-wires

104. Complications :
1. Most common- psuedarthrosis of talonavicular joint
2. Degenerative arthritis
3. Osteonecrosis

106. Labrinudi Arthrodesis
• -For correction of isolated fixed equinus deformity in children >
10yrs
• Inactive dorsiflexors & peroneals with active triceps surae cause
foot drop deformity –
• Wedge of bone is removed from plantar distal part of talus, so
that talus remains in complete equinus & remainder of foot is
repositioned to desired degree of plantar flexion

107. Complications
• 1. Ankle instability
• 2. Residual varus/ valgus
• 3. Psuedarthrosis of talonavicular joint

108. Ankle Arthrodesis
• For flail foot or recurrence of deformity after triple arthrodesis
• Compression arthrodesis is for older children & adolescents
• Subcutaneous plantar fasciotomy & lengthening of Achilles
tendon is done followed by ankle arthrodesis

109. Pantalar Arthrodesis
• Fusion of tibiotalar , talonavicular, subtalar, calcaneo cuboid
joints
• Indicated for flail feet with quadriceps paralysis
• Ankle fused in 5 to 10 degrees of plantar flexion
• Done in 2 stages- first in foot, 2nd in ankle
• Complications include psuedarthrosis, plantar callosities,
excessive heel equinus

110. Talipes Equinovarus
• Equinus deformity of ankle
• Inversion of heel & at mid tarsal joints
• Adduction & supination of fore foot
• d/t weakness of peroneals & normal posterior tibial
• Surgery: Anterior transfer of posterior tibial tendon to middle
cuneiform OR tendon can be split with lateral half transferred to
cuboid

111. Talipes Equino valgus
• d/t weak anterior & posterior tibial with strong PL, PB & triceps
is strong but contracted
• Triceps pulls foot into equinus, peroneals into valgus

112. Surgery:
• Subtalar arthrodesis & anterior transfer of PL, PB.
• Paralysis of anterior tibial alone—> moderate valgus, more
during dorsiflexion, disappear in plantar flexion
• Transfer of PL to 1st cuneiform, transfer of EDL OR Jones
procedure

113. Surgery for equino valgus:
• - In children 4- 10yrs— Extra articular subtalar arthrodesis +
achilles tendon lengthening –
• In skeletally mature— Triple arthrodesis + achilles tendon
lengthening

114. Talipes Calcaneus
• d/t Gastrocnemius-Soleus paralysis with active dorsiflexors
• Calcaneotibial angle - intersection of axis of tibia & line along
plantar aspect of calcaneus
• Normal is 70-80* , in equinus > 80*, in calcaneus< 70*
• Surgery: Plantar fasciotomy & Triple Arthrodesis followed 6
weeks later by transfer of PL & PB & post tibial to calcaneus

115. Calcaneotibial angle

116. REFERENCES
• Turek’s orthopaedics, 7th edition
• Campbell’s operative orthopaedics, 13th & 11th edition
• Tacdjian’s pediatric orthopaedics 3rd edition
• Kulkarni textbook of orthopaedics 3rd edition

117. THANK YOU